Group Benefits Quote – Benefits Logic

Company Name*

Address*

Street Address Address Line 2 City Province Postal Code

Phone*

Information required to provide a quote

Is there currently a benefit plan in place?*

Yes
No

Who is the provider?*

Please quote on:*

Basic Plan
Upgrade Plan
Both Plans

Owner's Name*

First Last

Owner's Email Address*

Enter Email Confirm Email

Gender*

Female
Male

Date of Birth*

DD

MM

YYYY

Coverage*

Single
Family

Optional Long Term Disability (LTD)*

Yes
No

Add Your Employees

Full time who have been employed for 90 days. If you have more than five employees we'll add them after with a follow up conversation.

Number of Full Time Employees*

Please enter a value between 1 and 5.

Employee One Gender*

Female
Male

Employee One Date of Birth*

DD

MM

YYYY

Employee One Coverage*

Single
Family

Employee One Optional Long Term Disability (LTD)*

Yes
No

Employee Two Gender

Female
Male

Employee Two Date of Birth*

DD

MM

YYYY

Employee Two Coverage*

Single
Family

Employee Two Optional Long Term Disability (LTD)*

Yes
No

Employee Three Gender

Female
Male

Employee Three Date of Birth*

DD

MM

YYYY

Employee Three Coverage*

Single
Family

Employee Three Optional Long Term Disability (LTD)*

Yes
No

Employee Four Gender

Female
Male

Employee Four Date of Birth*

DD

MM

YYYY

Employee Four Coverage*

Single
Family

Employee Four Optional Long Term Disability (LTD)*

Yes
No

Employee Five Gender

Female
Male

Employee Five Date of Birth*

DD

MM

YYYY

Employee Five Coverage*

Single
Family

Employee Five Optional Long Term Disability (LTD)*

Yes
No

Terms and conditions

Permission to quote*

I authorize Benefits Logic Inc to submit this information to ASSOCIUM Benefits for the purposes of obtaining a quote. This is strictly to be considered a quote, and not an offer of benefits. A formal filing of information will be required before an official contract and offer to insure will be issued. All of the information given here is correct and accurate. All information will be held in the strictest of confidence.

Yes
No